Advance Care Planning for Patients with Metastatic Pancreatic Cancer

Introduction to Advance Directives

The American Society of Clinical Oncology strongly recommends that goals of care, including advance directive discussions, occur with every patient with metastatic pancreatic cancer and their caregivers at the initial visit, as this disease has a median life expectancy of less than 1 year and a 5-year survival of only 2% 1, 2
The American Society of Clinical Oncology recommends discussing advance directives with patients at the first visit as part of a comprehensive goals-of-care conversation, framing it as a tool to ensure their wishes guide all future medical decisions, particularly regarding life-sustaining treatments if they become too ill to communicate 1, 2

Begin by explaining that metastatic pancreatic cancer is a serious illness where treatment focuses on controlling symptoms and extending quality life, but cure is not possible, and frame the advance directive as a way to maintain their control and autonomy throughout their illness 1, 2
Emphasize that advance directives are about the patient's values and preferences, not about "giving up" or stopping treatment, and ask who they would want to make medical decisions if they cannot speak for themselves (healthcare proxy/durable power of attorney for healthcare) 1, 2
Discuss treatment preferences in specific scenarios, such as if their heart stops, do they want CPR attempted, or if they cannot breathe on their own, do they want a breathing machine (mechanical ventilation), and what defines an unacceptable quality of life for them 1, 2

A formal palliative care consult should be offered at this first visit, as patients with metastatic pancreatic cancer have high symptom burden and benefit from early palliative care involvement, according to the American Society of Clinical Oncology 5, 6
Smoking cessation should still be offered throughout the entire oncology care continuum, including end-of-life care, with emphasis on patient preferences and values, as recommended by the National Comprehensive Cancer Network 3, 4

Document the advance directive discussion, the patient's stated preferences, and who their designated decision-maker is in the medical record at this first visit, and update this documentation at regular intervals as the patient's condition and preferences may evolve 1, 2
Revisit goals of care and advance directive preferences at key transition points, such as when starting new treatment lines, when disease progresses, when performance status declines, or when the patient raises concerns about their condition, as recommended by the American Society of Clinical Oncology 1, 2, 6